Author Topic: coinsurance vs copayment  (Read 2785 times)

wharta

  • Newbie
  • *
  • Posts: 34
coinsurance vs copayment
« on: January 18, 2010, 02:08:10 PM »
I am having trouble with this coinsurance  and copayment. I have a doctor who does in house and hospital patients and I am billing for both. The hopital does not collect copays and he does at his office. When I get the RA or EOB back I know it will show the amount owed by the patient- Coinsurance amount, does he still need to collect a copay amount from the patient as well or are these the same and would this be the coinsurance amount owed?

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: coinsurance vs copayment
« Reply #1 on: January 18, 2010, 04:02:28 PM »
My understanding is that Co-Pay is a set amount per office visit ($5, $15, $20), the patient CAN have a $20 co-pay and then the insurance pays 80% and the patient pays 20% "co-insurance" ON TOP OF the $20 co-pay.  Some patients only have Co-Pay, some only have Co-Insurance for office visits.

The difficulty in up front collecting is figuring the % co-insurance when you're not sure what the insurance is going to pay.  If there's a SET co-pay, the office should try to get that at time of service and explain to the patient that they will be sent a bill for the % they owe once the insurance responds.

The SET co-pay is usually for office visits, not hospital services, that may be where the confusion is.

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4706
    • Solutions Medical Billing
Re: coinsurance vs copayment
« Reply #2 on: January 19, 2010, 08:47:43 AM »
The eob should show the amount owed by the patient, whether it is copay, coinsurance, or both.  You should go by the amount indicated on the eob as the patient responsibility.

Michele
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: coinsurance vs copayment
« Reply #3 on: January 19, 2010, 01:04:07 PM »
Right, I thought wharta didn't understand the difference between co-pay and co-insurance.  If it's just what to bill the patient, it's on the EOB.

wharta

  • Newbie
  • *
  • Posts: 34
Re: coinsurance vs copayment
« Reply #4 on: January 26, 2010, 11:00:20 AM »
OK, one more thing. I have rec'd a ERA from Medicare- The amount billed was $105, and Medicare paid nothing. They show $91.85( the allowed amount) coinsurance 0, they have the $91.95 as the deductible amount, 0 copay and the adjustment amount.
So, the amount went towards the patients deductible and the patient nor the insurance owe anything?
They also have secondary insurance and it says the claim has been forwarded to them, but they will not pay anything on this claim either?

DMK

  • Hero Member
  • *****
  • Posts: 680
Re: coinsurance vs copayment
« Reply #5 on: January 26, 2010, 11:16:21 AM »
Most secondary or supplemental insurances pick up the Medicare deductible and co-pays.  Some secondary or supplemental insurances have a deductible too.  Once you receive the secondary EOB (and if it automatically crossed over it's fairly soon) then you'll know if you have to bill the patient.

Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 4706
    • Solutions Medical Billing
Re: coinsurance vs copayment
« Reply #6 on: January 26, 2010, 08:55:23 PM »
If the secondary doesn't pay, the patient definitely is responsible.  The Medicare eob should show patient responsibility $91.85.

Michele
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com